Post-Disaster Intervention Procedure and Techniques Available for Psychosocial Workers to Assist Survivors
Raquel E. Cohen MD,
Description: Introduces post-disaster intervention
techniques and procedures
Purpose: To review the scope and application of
assistance guidelines
Content: Defines the different procedures available to
workers
Learning
objectives: The worker will be able to acquire knowledge so as to choose the
techniques that help survivors. What are the guidelines that give support to
assist the survivors? What techniques are available?
Techniques
available in disaster are defined as active interactions whose aims are to
promote, complement and reinforce healthy functions and adaptive behavior of
the survivor. Although expressions of empathy are helpful, care must be
exercised not to reinforce or reward the “victim” role. Care should be taken
not to interfere with psychological defenses, which the survivor needs during
the initial period post-disaster. Establishing a relationship may be difficult
in the initial period because the survivor often has distorted thinking due to
high anxiety and cognitive blurring. They may be defensive, guarded and
overwhelmed. Once established the relationship the worker can offer options in
solving problems and can help the survivor by suggesting options in solving
problems so as to find the most feasible way of living day by day.
The worker needs to be aware that the survivor is going to
face different experiences as the community is reorganizing and as individuals
continue to return to function. Each of
these phases will stimulate varying emotions and attitudes presenting a
challenge to the worker who needs to ascertain what this changed behavior
means. What
this increasing knowledge of behavior change in relation to time lapse
indicates is that, intervention has to be "in sync" with the stage of
crisis resolution after the disaster impact.
Post-Disaster crisis counseling is defined as
"a mental health intervention technique useful in post-disaster events
that seeks to restore the capacity of the individuals to cope with the
stressful situation in which they find themselves. It has three aims: a) restoring
capacity of the individual; b) reordering and organizing their new world; and
c) assisting the victim to deal with the bureaucratic relief emergency
program." The methodology to bring about these objectives varies according
to the school of thought used by the worker. The reality circumstances mandate
a short, flexible, creative adaptable approach compared to our usual organized,
systematic clinical approach. This is an area where we continue to adapt
clinical skills and modify our approaches as we learn from one disaster to the
next. Differentiating variables like age, sex and cultural backgrounds taught
us that both reactions and successful interventions differed in children,
adults and the elderly of different cultures.
The
goal of post-disaster psychological intervention is to alleviate a survivor’s
emotional distress and/or cognitive disorganization and to suggest corrective
action and offer appropriate information.
The worker can help survivors identify, interpret and normalize their
overwhelming emotions, understand the normal reactive nature of feelings, and
recover a sense of capability and hopefulness.
Goals
in Helping Survivors
·
To increase
understanding of stress reactions so as to mitigate its effects
·
To minimize
the impact of trauma by increasing coping strategies
·
To obtain and
identify concrete types of help
·
To develop and
improve communication to aid in problem-solving skills and identify concrete
types of help
·
To develop and
improve communication to aid in problem-solving skills
·
To restore
social coping and functioning within rapidly changing systems and disorganized
social structures
·
To support
relationships with other survivors and staff of agencies providing health care,
housing, and economic assistance
·
To continue to
foster coping skills and adaptation to post-disaster changes in the community
so that survivors will be able to carry on and respond normally to an abnormal
traumatic event and to the changes that have occurred in their lives and
livelihood.
Post-disaster Crisis training –(based 0n Dr. Bernard Beitman ‘LEARNING PSYCHOTHERAPY”)
Crisis Intervention Skills And
Attitudes For Workers Post-Disaster: What are the goals of an effective
training program?
We must select a
limited number of skills that if effectively taught, will lead to effective
crisis intervention. This objective requires careful selection from a wide
variety of potential alternatives based on research and experience. Trainers are encouraged to examine their own
thinking and to apply critical attitudes to what they do and how they do
it. They learn to measure their
effectiveness and respond to these evaluations with a sharpening of behavior
and thinking. It aims to teach workers
to think flexibly at decision points in order to tailor intervention for
specific survivors at specific points in the orifices of crisis resolution.
The training program
is based upon 2 constructs:
The stages of crisis
intervention – this is a process in a series of interventions-reactions
proceeding through the passage of time.
This series of interactions can be divided into stages. Each stage has goals, with mini-objectives
within the process
STAGES OF CRISIS INTERVENTION THROUGH TIME ENGAGEMENT: build collaborative relations with survivor
PATTERN SEARCH:
facilitating the ability to establish a working alliance by using interest of
survivor
CHANGE: strategies to
help the survivor return to
previous self
TERMINATION:
attempt to separate from survivor and to help maintain gains in coping and
adapting post–disaster
BASIC ‘BOTTOM-
First Stage: approval
and support; allow the to tell their story; instill hope; reassure; offer
information; permit reflection and self disclosure
Second Stage: open
and closed-ended questions; Information gathering; cognitive focus; behavioral,
feeling, relationship focus
Third Stage: clarification;
education; reality testing; reinforcement and encouragement; offering insight
connections
SET LIMITS
– The array and extent of problems and needs of survivor are numerous and
difficult to resolve. This will
necessitate careful considerations of priority and possibility of
solutions. Carefully weighing the
solutions for feasibility and salience has to be considered at every step of
the way. Time phases will present
differences in intensity, acuteness and emergency. Give examples of situations and approaches. Link to some real disasters
OBTAIN INFORMATION --To get oriented to the situation in which
the survivor finds himself there is a need of specific data while at the same
time trying to establish a relationship by being sympathetic and conveying an
attitude of caring. Time is of the
essence, both because of the number of survivors and their needs and the urgency
to solve the needs of the survivor. This
necessitates a focused interrogatory interaction, a balance between support and
data.
GIVE -- How much expression of compassion, how
far one goes to solve problems, how many resources one tries to obtain for the
specific survivor is a question of skills and intuition plus experience in
weighing ones own possibilities for success.
SUPPORT -
- Extending support to assist in problem solving is a continuous activity to
help survivors. Research has shown that
this activity may be one of the most important for successful coping, problem
solving and adaptation of the survivor as they proceed from the first traumatic
moments through the process of mourning to finally accept the difficult new
situation in which they will find themselves.
FOCUS --Keeping
a clear direction and objective of all the activities to assist a survivor is a
difficult task due to the myriad possibilities and shifting situations in which
both the worker and the survivor find themselves and their relations
evolve. Supervision of the workers
activities is very helpful to assist the in this objective.
CLARIFY -
confusion, perplexity, unrealistic feelings and expectations are emotions of
being a survivor. They need assistance
to check reality and plan for their future; this has to be done with
sensitivity and skill. Sometimes only
giving part of news (death of a dear one, complete loss of a home) and in slow,
small doses can the survivor process reality without recurring to unhealthy defenses. Care must be taken to handle denial used by
the survivor in order to keep their sanity.
HOPE --A hopeful attitude should be conveyed to
the survivor “together we will work and process the painful situation”. This does not mean that one cheerfully or
unrealistically offers solutions.
CATHARSIS --Accepting
the needs of the survivor to express painful feelings of guilt, regret, anger,
sadness and crying will be part of allowing feelings to be shared. It is important not to offer any explanation
or efforts to assuage these expressions – sharing and listening in a comforting
attitude is important for the survivor to share with their worker and not feel
judged or belittled.
COGNITION --The
use of awareness, problem solving, options and reality checks is a constant
technique of counseling and crisis intervention in disaster. Methods of coping needs to be discussed and
options using the best judgment for what is best for the survivor has to be
explored
BEHAVIORS - Documentation
of worker and survivor behavior after a disaster will run the gamut of
available possibilities of human reactions..
Expectable behavior of workers is part of the training necessary to work
in this field. It needs constant
support, and supervision The behavior of survivors has
been documented according to the phases post-disaster, age, sex, roles,
ethnicity, socioeconomic status, religion etc (Use links to other documents)
SELF-CONTROL
– This skill is necessary for workers who will experience all kinds of
emotions, ranging from compassion to anger, shame and powerlessness Use link to
documents)
FEELINGS –Every
variety of human emotions are activated in workers and survivors in a disaster
situation
INSIGHT—assisting
survivors to gain insight into their
CHANGE –everything
in the life of a survivor will suffer some degree of change due to the impact
of the catastrophic event. With is
change will come the realization of multiple loses so that mourning and coping
with these events is a perennial activity of counseling the survivor.
REINFORCE -
there is a constant need to remind the survivor of their strength, capacity,
skills, and resources to strengthen the behaviors of the survivor who feels
defeated and powerless
RESISTANCE-DENIAL --this defense is a primary defense during
the initial period following the awareness of the impact produced by the
disaster it is expectable and should be handled as a healthy capacity of the
organism no become overwhelmed by the terrible situations in which they find
themselves
CHALLENGE -working
with survivors is one of the most challenging, difficult but rewarding
professional activity. Many workers
expect this perception to last throughout their mission but it is important to
realize that after several months in the field many of their tasks will be seen
as routine.
RELATIONSHIP –
the dramatic interaction between workers and survivors builds a different and
special type of relationship. It is
important for the worker to guide this relationship in an ethical and
professional manner
WORKERS NEEDS----Alert
to BURN OUT; FEELINGS OF OBNIPOTENCE; PATRONIZING; PATERNALISM INTERPERSONAL. –Relationships with multiple individuals
develop in the setting of working in a disaster. Each one has specific characteristics, which
should be well defined with clear objectives for the worker – Red Cross, FEMA,
Civil Defense, Mental Health, Police, Medical Personnel, Funerary Directors,
Shelter personnel, Coroner etc
Consultation and Education are two areas of
assistance that are being developed in addition to the direct face to face with
intervention with the survivor. As emerging approaches in disasters increased
the awareness that large number of non-mental health workers plus the public at
large needed more information these two approaches have been added to programs
of assistance. The model evolved using the consulting methods developed in
community psychiatry (Caplan 1970) slowly evolved
into the objectives of 1) increasing the capacity of the consultee
to manage the survivor's planning 2) increase the knowledge of the consultee to deal with the organized agencies tasks
addressing the needs of individuals after disasters. The lessons we learned,
after acquiring the knowledge of the multilevel disaster assistance bureaucracy
that emerges after a disaster impacts a community, had to do with the use of
power and decision-making. In national declared emergency the power of the
government representative is decisive. We learned that negotiating with them
needed sensitive consultation techniques. The steps that all of us in community
psychiatry had learned, that is, for example, to get permission and be invited
as consultants, had to be carefully attended to. Suggesting methods to deal
with victims, incorporating mental health values in decision making about a
victim at times collided with other professional values, rules and regulations
Attention had to be given to the victim's need,
the role of the emergency worker and the resources of the Disaster Assistance
Program. Again, like crisis intervention had to be in "sync" with
sequential stages of the victim's need, consultation to assist the consul tee’s
responsibilities had to be attuned to the governmental agency needs according
to sequential program activities.
Education
Opportunities for media communication and
dissemination of mental health information present themselves following a
disaster. The human story in disaster is very compelling and media
professionals seek professionals to interview - at a rapid pace. In the midst
of community crisis, the impact of these messages exerts a strong influence.
There are two specific areas that offer
objectives to be accomplished by educational methods. One area deals with our
knowledge of how the population has been psychologically affected by the trauma
and the sequences of the stress response to the disaster. The other area is to
offer knowledge of how the mental health system will respond and what we as
professionals have to offer in post-disaster situations. Each of these areas
has a) methods b) content and c) structure to disseminate knowledge.
The opportunity to disseminate knowledge to the
public serves as a preventive method because it explains aspects of novel
behavior and reactions that are unexpected and by being unfamiliar can potentiate further stress. Studies suggest that if a victim
can derive an explanation for their reactions it will influence the person's
adaptive response. If individuals are forewarned, they will anticipate their
unusual expressions of emotions and then can accept them as appropriate under
the circumstances.
Disseminating information about the mental
health services, including consultation and education, facilitates the actual
operations of mental health interventions.
Summary
Many of the skills used by professionals
post-disaster are known to them but need to be adapted so as to assist the
survivor who has been traumatized by the disaster, is not a patient and is not
ill. A small percentage of survivors
will go on to show some signs of pathology over time and need to be referred to
the appropriate services.